Clinical audit is a quality improvement process to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change.
All practising ophthalmic clinicians should be actively involved in the clinical audit of their own and their service’s care.
Clinical audit measures whether healthcare is adhering to recognised best practice standards and provides a mechanism for change and action where improvement is required. All practising ophthalmic clinicians should be actively involved in the clinical audit of their own and their service’s care.
Defining a clinical data set
A clinical data set is an operational standard which is a list of well-defined variables relevant to clinical activity. The information must be unambiguous and should not contradict existing standards, so for example date of birth is recorded in a standard manner already established in the NHS data dictionary. More ‘specialist variables’ e.g. things to do with biometry for example which currently do not exist in the data dictionary must be defined de novo in the cataract data set. Data sets for both the AMD and cataract audits are available to download on the NOD Audit website.
The benefits of routine data collection
The data set is not a ‘form’ to be filled out; it refers to the variables to be collected and the format which they should take. It is expected that the data will be collected as part of routine care and other benefits such as audit and revalidation will be entirely secondary. It is about the standardisation of data content, meaning and format for electronic use. Once approved, EMR systems will need to conform to this standard.
Not every item of data will be mandatory. This exercise is not being done for the purposes of revalidation but should help with that process as a secondary benefit, predominantly when EMR systems are in place. If electronically collected data all have the same meaning regardless of locality and the EMR system being used then this will ease the burden of the collection of comparable cross-boundary data and the burden upon doctors individually.
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Contact The Royal College of Ophthalmologists via email: [email protected].